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Glossary of healthcare terms
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The following is a glossary of the terms used in the Healthcare Policy project. Each term on this page includes a brief definition. For more information, click on a term to be directed to a more in-depth page on the subject.
Note: If the term is not clickable, an expanded page has not yet been created. Ballotpedia staff are working on building those term pages on a regular basis.
Terms
Health insurance terms
- The actuarial value of a plan is the overall average percentage of costs an insurance plan will pay for covered benefits.[1]
- Balance billing refers to the practice of billing a patient for the difference between the provider's charge for a medical service and the amount negotiated by the patient's insurer for that service.[2]
- In healthcare, bundled payments are a reform of the traditional fee-for-service reimbursement model. When a third-party payer, such as an insurance company or Medicare, adopts a bundled payment model, a group of doctors and hospitals together receives a lump sum to cover all of the services associated with the treatment of a condition.[3]
- Catastrophic health plans offer the lowest level of insurance coverage and are intended to protect the insured from worst-case scenarios.[4]
- Coinsurance is the percentage of cost the insured must pay for a covered service after they have met their deductible.[5]
- Copayments are fixed amounts paid for a covered medical service once the insured has met their deductible.[6]
- Cost sharing is an insured individual's costs for covered benefits during their policy period.[7]
- A deductible refers to the amount an insured person must pay for healthcare services before his or her insurance plan starts to pay.[8]
- In a fee-for-service health insurance system, healthcare providers are paid for each distinct service they perform.[9]
- Flexible spending accounts are accounts used to pay for out-of-pocket health costs.[10]
- A group health plan is a policy purchased by an employer from an insurance company and offered to their employees.[11]
Health maintenance organization
- Health maintenance organizations are groups of affiliated insurers and medical providers. Typically, an HMO insurance plan will limit coverage to providers that are members of or contract with the HMO, not covering out-of-network services.[12]
- Health reimbursement accounts are accounts owned and funded by employers as part of their group health plans to reimburse employee medical expenses.[13]
- Health savings accounts are financial accounts that allow for tax-free deposits and withdrawals for healthcare expenses. In order to open a health savings account (HSA), an individual must first be enrolled in a high-deductible health plan and have no other comprehensive health insurance plan.[14]
- High-deductible health plans are health plans with higher-than-average deductibles. The amount a deductible must reach to qualify as an HDHP is set annually by the IRS. In 2016, the threshold for HDHPs was $1,300 for an individual or $2,600 for a family.[15]
- Individual health plans are insurance plans purchased by individuals or families that are not plans offered to them through their employer.[16]
- A medical loss ratio (MLR) is the portion of premium revenue a healthcare insurance company spends on claims, medical care, and healthcare quality for its customers.[17]
- Medical underwriting refers to the process by which a health insurer evaluates whether to accept an applicant for health coverage and what premium to charge the applicant.[18]
- Out-of-pocket costs encompass all expenses one may pay for healthcare services that are not covered by insurance or reimbursed.[19]
- Pay-for-performance in healthcare is a third-party reimbursement model that uses incentives to encourage providers to improve the quality and cost of care.[20]
- A health problem that existed in a time before new health coverage begins is referred to as a pre-existing condition.[21]
Preferred provider organization (PPO)
- PPO plans are health plans that contract with medical providers to form a network of providers for the insured. The insured pay less for using providers in the network and may use out-of-network providers for an extra cost.[22]
- A premium is the price that an insured person or sponsor (such as an employer) pays regularly for an insurance plan.[23]
- Rate review refers to the process by which a state insurance department reviews an insurance company's planned premium increases before they are applied to health plans.[24]
- Special enrollment periods are periods of time outside the regular open enrollment periods in which one may sign up for health coverage.[25]
- In value-based purchasing, payments to providers are linked to the quality of care they provide to patients.[26]
Healthcare delivery terms
Accountable care organizations
- An accountable care organization (ACO) is a group of doctors, hospitals, or other healthcare providers that work together and take on some risk of financial losses, with the purpose of delivering high-quality care at a lower cost.[27]
- Acute care refers to medical care that is short-term and typically time-sensitive, such as treatment for severe injuries and illnesses.[28]
- Direct primary care is a retainer-based model, meaning that patients pay a flat fee—called a retainer—to their physician, covering all their primary care visits and services.[29]
- Electronic health records (EHRs) are digital versions of patient medical files that can collect more comprehensive health histories from multiple providers than paper records.[30]
Affordable Care Act terms
- Co-ops were created by the Affordable Care Act as nonprofit organizations that are controlled by and insure the same people.[31]
- In healthcare, community rating refers to the requirement that health insurance providers charge the same health insurance premiums to all people within a certain geographic area.[32]
- A health plan that is guaranteed issue is sold without consideration for health, age, gender, or other factors, meaning insurance companies cannot deny coverage to qualified individuals.[33]
- The Affordable Care Act (ACA), also known as Obamacare, provided for the creation of health insurance exchanges, also called marketplaces, where consumers could browse and purchase plans. Exchanges are "accessible through websites, call centers, and in-person assistance."[34]
- The risk adjustment program required insurers that sell individual and small group plans (both on and off the exchanges) and have relatively lower risk to make payments to individual and small group insurers with relatively higher risk.[35]
- The temporary risk corridor program was established under the Affordable Care Act to limit the losses and gains of insurers in the reformed individual market.[36]
- The transitional reinsurance program established by the Affordable Care Act (ACA) required most health insurers, including employers that self-fund health plans, to pay a fee to the federal government based on their enrollment figures for a plan year. The fee went toward payments to insurers providing plans on the individual market that covered high-cost individuals.[37]
Miscellaneous terms
- All-payer claims databases (APCDs) are statewide databases that collect healthcare claims data from insurance companies, government agencies, and other entities that pay for healthcare on behalf of individuals.[38]
- Certificate of need (CON) laws are state-level regulations that require healthcare institutions, such as hospitals and nursing homes, to obtain approval from state officials before moving forward on a large capital expenditure project, such as a new facility or new equipment.[39]
- Prior to the Affordable Care Act, Medicare beneficiaries with prescription drug coverage (Part D) often had a gap in such coverage referred to as the "donut hole." This coverage gap was a period in which the beneficiary was between their initial coverage limit and their catastrophic-coverage threshold.[40]
- Right-to-try laws are state-level reforms that aim to allow terminally ill patients to gain access to experimental drugs without the permission of the Food and Drug Administration (FDA).[41]
See also
External links
- Healthcare.gov glossary
- USA Managed Care Organization, "Health Care Terminology Glossary"
- AcademyHealth, "Glossary of Terms Commonly Used in Health Care"
Footnotes
- ↑ Healthcare.gov, "Actuarial Value," accessed May 26, 2016
- ↑ Forbes, "What Is Balance Billing?" January 26, 2015
- ↑ Health Affairs Blog, "The Payment Reform Landscape: Bundled Payment," July 2, 2014
- ↑ Healthcare.gov, "Catastrophic Health Plan," accessed May 25, 2016
- ↑ USA Managed Care Organizations, "Health Care Terminology Glossary," accessed May 25, 2016
- ↑ USA Managed Care Organizations, "Health Care Terminology Glossary," accessed May 25, 2016
- ↑ Healthcare.gov, "Cost sharing," accessed May 26, 2016
- ↑ USA Managed Care Organizations, "Health Care Terminology Glossary," accessed May 25, 2016
- ↑ Healthcare.gov, "Fee for Service," accessed May 26, 2016
- ↑ Healthcare.gov, "Flexible Spending Account," accessed May 30, 2016
- ↑ Healthcare.gov, "Group Health Plan," accessed May 26, 2016
- ↑ BBC, "Health Maintenance Organization / HMO," February 22, 2000
- ↑ Healthcare.gov, "Health Reimbursement Account (HRA)," accessed May 30, 2016
- ↑ Kaiser Health News, "FAQ On HSAs: The Basics Of Health Savings Accounts," November 9, 2011
- ↑ Healthcare.gov, "High deductible health plan," accessed May 26, 2016
- ↑ Healthcare.gov, "Individual Health Insurance," accessed May 26, 2016
- ↑ Congressional Research Service, "Medical Loss Ratio Requirements Under the Affordable Care Act," August 26, 2014
- ↑ Healthcare.gov, "Medical Underwriting," accessed May 26, 2016
- ↑ Healthcare.gov, "Out-of-Pocket Costs," accessed May 25, 2016
- ↑ RAND Corporation, "Efforts to Reform Physician Payment: Tying Payment to Performance," February 14, 2013
- ↑ Healthcare.gov, "Pre-Existing Condition," accessed May 26, 2016
- ↑ Healthcare.gov, "Preferred Provider Organization (PPO)," accessed May 30, 2016
- ↑ USA Managed Care Organizations, "Health Care Terminology Glossary," accessed May 25, 2016
- ↑ Healthcare.gov, "Rate Review," accessed May 26, 2016
- ↑ Healthcare.gov "Special Enrollment Period," accessed May 31, 2016
- ↑ Healthcare.gov, "Value-Based Purchasing (VBP)," accessed May 30, 2016
- ↑ Politico, "Understanding Obamacare: POLITICO's Guide to the Affordable Care Act," accessed October 21, 2015
- ↑ World Health Organization, "Health systems and services: the role of acute care," accessed May 26, 2016
- ↑ American Academy of Private Physicians, "Direct Primary Care Offers Affordability in Private Medicine," December 22, 2014
- ↑ American Academy of Family Physicians, "Introduction to Electronic Health Records (EHRs)," accessed March 25, 2016
- ↑ Healthcare.gov, "Co-Op," accessed May 30, 2016
- ↑ Healthcare.gov, "Community Rating," accessed May 26, 2016
- ↑ Healthcare.gov, "Guaranteed Issue," accessed May 26, 2016
- ↑ National Conference of State Legislatures, "State Actions to Address Health Insurance Exchanges," October 13, 2015
- ↑ The Henry J. Kaiser Family Foundation, "Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors," January 22, 2014
- ↑ The Henry J. Kaiser Family Foundation, "Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors," January 22, 2014
- ↑ Internal Revenue Service, "ACA Section 1341 Transitional Reinsurance Program FAQs," accessed October 14, 2015
- ↑ Governing, "More States Create All-Payer Claims Databases," February 4, 2014
- ↑ National Conference of State Legislatures, "Certificate of Need: State Health Laws and Programs," accessed April 11, 2016
- ↑ Healthcare.gov, "Donut Hole, Medicare Prescription Drug," accessed May 26, 2016
- ↑ National Conference of State Legislatures, "'Right to Try' Experimental Prescription Drugs State Laws and Legislation for 2014 & 2015," March 31, 2015
